Provider Demographics
NPI:1881447795
Name:RONDON, BRYAN ANTHONY
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:ANTHONY
Last Name:RONDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-4137
Mailing Address - Country:US
Mailing Address - Phone:608-774-8249
Mailing Address - Fax:
Practice Address - Street 1:1748 BELOIT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-3031
Practice Address - Country:US
Practice Address - Phone:608-774-8249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIDCQ-122301574171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor